Pulmonology Coding Alert

Sometimes the code refers to a service performed on one lung only.

Lung care coding often hinges on whether your physician administered a service on both of a patient’s lungs, or if he only addressed the left or right. To make matters more confusing, some codes are inherently bilateral, while others apply only to one side.

To stem confusion, it’s important to know not only the bilateral and unilateral coding rules, but also to get a handle on which codes can be billed twice if you address both lungs, and which can’t. Read on for a quick primer that can help you sort through these issues.

Don’t Expect Double the Payment

You could be missing out on major reimbursement for bilateral claims if you’re not clear about when to apply modifier 50 (Bilateral procedure)  or the anatomical modifiers LT (Left side) and RT (Right side). However, if you report a code bilaterally, you shouldn’t expect twice the payment. Reimbursement for a bilateral service typically comes in at 150 percent of the fee schedule amount rather than at 200 percent, according to Medicare guidelines.

Before you decide which modifier best suits a given claim, you should consult the 2019 Medicare Physician Fee Schedule database, which is available on the CMS website and offers the following indicators for each code:

• 0: Bilateral surgery rules don’t apply, and you should not use modifier 50.
• 1: Bilateral surgery rules apply and you can collect 150 percent of the fee schedule amount if you use modifier 50 or LT/RT when the procedure is performed bilaterally.
• 2: Bilateral surgery rules do not apply because the code is already priced as bilateral, so you should not use modifier 50.
• 3: The standard payment adjustment for bilateral procedures does not apply and you can collect 100 percent of the fee schedule amount for each side. Typically services with a “3” refer to radiological or other diagnostic tests.
• 9: The bilateral surgery concept does not apply.

In most cases, pulmonology coders will see the indicators of zero, one, and two on the fee schedule. You’ll find the “3” and “9” indicators much less frequently for the chest codes.

Example:  Your physician performs a biopsy of the bronchioalveolar regions of both the left and right lungs using needle aspiration. You should report 31629 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i]). You don’t need to append modifier 50 or the LT/RT modifiers, because this code has an indicator of “0,” suggesting that the bilateral surgery rules don’t apply. By reviewing the code descriptor, you can often determine this without consulting the fee schedule, since it refers to “biopsy(s)” and “bronchus(i),” indicating that the code applies whether one or more biopsies are taken.

If you need to provide clarity on your claim, you may report modifiers LT or RT, either in combination or singly, but keep in mind they would be used for information purposes only and would not increase your payment.

Seek Advice From Private Payers in Writing

When dealing with non-Medicare payers, you should ask your insurers how they want you to report modifiers 50 and LT/RT. Not all private payers follow CMS guidelines. Some insurers will specify when they prefer modifier 50 and when they require modifiers LT/RT. Other payers prefer modifiers LT/RT in all circumstances because they think those modifiers are more specific than modifier 50. Even when requiring modifier 50, some payers have different ways that they want you to report the services. Some carriers might want you to report your procedure code using two line items, appending modifier 50 to the second code. Other carriers might want the code reported only once, with modifier 50 appended.

Protect yourself: Always be sure to get the payers’ coding recommendations and payment guidelines in writing in the event of audits or claim reviews, coding experts say.